Provider Demographics
NPI:1053059220
Name:CENTURION SURGERY CENTER OF JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:CENTURION SURGERY CENTER OF JACKSONVILLE, LLC
Other - Org Name:CENTURION SURGERY CENTER OF JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-256-2754
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224
Mailing Address - Country:US
Mailing Address - Phone:904-593-5146
Mailing Address - Fax:904-593-6642
Practice Address - Street 1:5191 FIRST COAST TECH PKWY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224
Practice Address - Country:US
Practice Address - Phone:904-593-5146
Practice Address - Fax:904-593-6642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical